Wiki unable to perform exam or obtain review of systems

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rlh27

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one of my docs was asked to give a neurological consult for a pt with altered mental status. he states he was unable to obtain a ROS because the patient was agitated, moaning, restrained, and not responsive towards questions. the patient was then given sedatives and the doc states that he was unable to perform an exam because the patient was "sleeping/sedated"

I've got a cheif complaint, a history, vital signs, studies and tests. the MDM includes giving the patient meds and following up. the doc wants a 99221 but i don't think the "exam" qualifies.

any thoughts?
 
It depends if the physician is using the 1995 examination guidelines or the 1997 examination guidelines which are more detailed.
 
99499 Unlisted E/M

It's hard to tell without seeing the actual documentation.

Have you considered using 99499 Unlisted E/M and basing your fee on 99221?

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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